Stress Fractures of the Foot

SYMPTOMS

There is increasing localised pain over a bony prominence, often with no direct preceding trauma. The start of symptoms can be acute. There is often a history of suddenly increased training intensity or jumping or running on hard surfaces. A number of famous footballers’ metatarsal stress fractures have figured in the media over the last few years.

ETIOLOGY

A stress fracture is preceded by an imbalance in impact/loading and adaptive bone turnover. ‘Too much too soon’ is the typical cause in the healthy young athlete; in elderly athletes osteoporosis may play a role; in younger athletes who have been temporarily immobilised inactivity related osteopenia can play a role.

INVESTIGATIONS

X-ray confirms the diagnosis around three weeks from onset when there is callus formation. MRI and bone scans pick up this injury within a few days from onset and can be recommended in unclear cases.

TREATMENT

Initially modify the training avoiding or decreasing impact to the foot. The location of the stress fracture is important for outcomes. There are a few stress fractures that need to be treated with utmost caution: MT V, the Navicular bone and talus, calcaneus and sesam bone fractures adjacent to MTP I. These may need immobilisation or sometimes surgery. Most other stress fractures, unless with underlying bone problems, will heal within six to twelve weeks by just modifying activities.

REFERRALS

Refer to podiatrist and physiotherapist for mild symptoms and to orthopaedic foot surgeon if stress fractures on the above locations.

EXERCISE PRESCRIPTION

Rest will not help so allow all kinds of sporting activities using well-fitting shoes and decrease impact to fractured area. A nonweight- bearing boot can be used temporarily. If there is pain on impact, suggest cycling, water exercises or swimming as alternatives to running and jumping sports.